Kevin Bain, DO1, Derek Lim1, Andrew Lelchuk, DO2, Vadim Meytes, DO3. 1NYU Langone Hospital – Brooklyn, 2Nova Southeastern University College of Osteopathic Medicine, 3Vassar Brothers Medical Center
Introduction: Intra-abdominal abscess (IAA) after laparoscopic appendectomy (LA) is a major cause of morbidity, can prolong hospitalization, and can increase hospital costs. Risk factors include diabetes mellitus, obesity, age, and perforated appendicitis.
Case Report: 15 year old female with 3 days of right-sided abdominal pain. A CT scan demonstrated perforated appendicitis, and the patient was taken for diagnostic laparoscopy. About 500 milliliters of pus was evacuated from the peritoneal cavity. A perforated appendix was visualized and removed in the normal fashion. Irrigation with 3 liters of normal saline (NS) was performed.
Postoperatively, the patient continued intravenous antibiotics. She persisted to have an uprising leukocytosis to 13.0 K/uL on postoperative day 5. Further imaging demonstrated multiple intra-abdominal abscesses. Interventional radiology performed transgluteal drainage, with placement of a pigtail catheter. The patient was discharged home on antibiotics, with the catheter in place.
Discussion: Postoperative IAA after LA remains a debated topic. Studies have shown as high as a 20% abscess formation rate status post appendectomy for perforated appendicitis. Debate still remains between irrigation versus suction alone. The theory behind irrigation is dilution of bacterial concentration. Others believe irrigation actually spreads contamination, and dilutes immune system mediators.
In 2008, Hussain et al. described a prospective study of 283 patients with acute appendicitis. Their technique to reduce postoperative IAA included irrigating all four quadrants of the peritoneal cavity with 3 liters of NS. No patients developed postoperative IAA, and they concluded that copious irrigation and drainage significantly decreased the rate of postoperative IAA.
In 2015, Cho et al. performed a retrospective cohort study to examine risk factors for postoperative IAA after LA, and concluded the exact opposite. They analyzed 1,817 LA and the only difference was that “peritoneal irrigation was performed significantly more often in the IAA group than in the non-IAA group (p < 0.001).” They concluded that peritoneal irrigation increased the incidence of postoperative IAA.
More recently, in 2016 Snow et al. published the first prospective, randomized controlled trial (RCT) in adults comparing irrigation versus suction alone during LA. In 81 patients, they found “the rate of IAA was equivalent between groups treated with peritoneal irrigation and suction alone.” This conclusion coincides with the only other prospectively conducted RCT on this topic, which was conducted in children.
Conclusion: There remains to be limited high-quality prospective studies to compare peritoneal irrigation to suction alone for preventing IAA after LA.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 91984
Program Number: P017
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster
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